[Surgical procedure after primary chemotherapy of breast carcinoma--an unresolved clinical problem]

Neoadjuvant chemotherapy has more and more become clinical routine during the past years. Results from large randomized trials like NSABP-B18 show that survival parameters are not affected if sequence of therapy is changed. Survival parameters have been intensively studied, but surgical standards after primary chemotherapy are much less well defined. Results from the early trials comparing lumpectomy or quadrantectomy with mastectomy are generally transposed to the neoadjuvant situation. In this context the "result of downstaging" is surgically treated like otherwise the primary tumor would have been treated. Though local recurrence rates reported after primary chemotherapy are not increased within the whole population this may not be correct for subgroups. E.g. within the NSABP-B18 trial significantly higher local recurrence rates are reported for those patients who initially were proposed to have mastectomy and who actually received lumpectomy after effective primary chemotherapy. Another unresolved problem is surgery after complete remission, which as histopathology demonstrates corresponds often not to pathological complete remission. Therefore in most cases the initially involved area is resected, which may result in a more radical surgical approach to complete remission than to partial remission. Further standardisation of surgical approach to patients after neoadjuvant chemotherapy should be evaluated within phase III trials.